JS: Well, I guess that’s the point: dealing with these situations is a very inexact process, and one that relies a lot on intuition and judgment. Intuitively, I wanted to reach out and offer some kind of support. But at the same time the enormity of this guy’s pain was such that I felt I should say nothing, and just be there. And I guess veterans’ family members may be wondering how they can tell when they need to be proactive in offering support and when they need to give their loved one some space. Are there any clear guidelines here?

FO: It’s a good question. First of all, it’s not too good to say something that is superficially comforting. The “there-there” kind of statement, or, “You’ll be all right.” I think it’s good to remember this phrase I learnt as a Red Cross volunteer, which is called “the ministry of presence.” It’s just plain being there – and if you have to say something you might say, “Thanks for telling me such a hard truth. I’m listening.” Or, “Is there more?” But you don’t have to say something optimistic when it isn’t called for.

Now, what I do as a psychiatric listener is try to figure out what’s going on. And what you just described to me sounds like the person brought himself back to the trauma scene, so, as he’s talking to you he’s going back into the trauma. I wouldn’t necessarily rush him out of the trauma, and very obviously change the subject. I think I would want to be there with him to be sure he had said it all, then move on to something else, and not leave him right in the middle of his trauma story, even if I had to keep another patient waiting. That’s a decent and important thing to do.

JS: We do know, from research and personal reports, that one thing that makes dealing with trauma much more difficult is a sense of being alone or of feeling abandoned. So, I guess just having someone there, just having another human presence, can help people with the process of dealing with trauma.

FO: Yes, good point.

JS: But can we get back to the matter of advice for veterans’ partners? A veteran’s struggles can take a tremendous toll on those closest to them. What can the wives and husbands of veterans do to maintain their own psychological well-being?

FO: This is important to discuss. There’s a term that’s relevant here and that’s “care-giver burden,” where the loved one in the family becomes a care-giver and there is a certain burden. And sometimes that means that you, the family member, need to get help yourself. It could be professional help, and it could be a social worker, a psychologist, even a psychiatrist who takes you on as a patient due to your role as a family member. You also may need a rest now and then. So, everything that’s useful for the person with PTSD is useful for the person who’s caring for them. That involves taking care of your fitness, understanding your own spirituality and being sure those needs are met, keeping up your sense of humor, having a decent diet, and getting educated about PTSD-related issues.

JS: This is critical, isn’t it, because they’re giving a great deal to their partners. They’re having a lot of demands made on their physical and psychological resources, and they’re not necessarily getting a lot back because the people they’re helping are obviously struggling to deal with their own problems.

FO: Absolutely. You know, I’ve had a number of PTSD patients who have been referred to me by their spouses. It’s often women who are the spouses. They read, and they find out about people like me. I’ll bet a lot of us who are known for our work in PTSD are approached by other family members. We get accustomed to that. And I find myself talking with my patients who have PTSD about their wives. There’s one wife of a marine, and she’s a lovely young woman—they’re both in their 20’s—and it’s a tremendous resource for me, as I deal with her husband, that there’s someone in that household who’s tolerant, caring, resourceful. In some situations I find that I get ideas from a perceptive spouse that I hadn’t thought of.

JS: There will be some veterans who have been dealing with intense psychological pain for months or even years. Some will be wondering: Will I ever feel normal again? How long will it take to sort out my problems?

FO: And the answer to that is, the prognosis is generally good. There are some very hard cases, and the hard case isn’t just because the trauma was so difficult, it’s because the life that you’re returning to is so difficult. But nobody likes to give a general statistic about how long PTSD going to last.

JS: Obviously each case will be different, and someone’s background, as well as their personal qualities, will influence how they react to and deal with PTSD.

FO: Yes, that’s right. I’m working with Vietnam veterans now, and it’s 40 years since the war, but they’re still deeply affected. But then they have other problems: they get diabetes; one guy had a couple of strokes; another is in a very miserable financial situation. The PTSD is part of it, but there are complicating factors. I can say this: all of my Vietnam-era PTSD patients are involved with me in helping younger veterans. I’ve kind of conscripted them, and I think they’re getting some gratification out of it. So, there’s quite a fraternity—and now there’s a sorority too—of people out there who have dealt with these problems, are still struggling, but they have enough ability and experience and wisdom to help others.

JS: What would you say to any veteran reading this who is really struggling, who’s feeling overwhelmed, who’s feeling desperate, who’s beginning to lose hope? What would you say to someone like that?

FO: Well, you always want to inspire hope, optimism, confidence—but in a realistic way. To go through a period, even a long period, of depression is part of the expected consequence of having been to war and having seen its impact, particularly on people we love and we bonded with. So, the cruelest legacy of the war is to have been right there and to have witnessed the killing of one of our brothers and sisters in arms. I think that’s the worst consequence.

But short of that, there is a lot of trauma and tragedy that our veterans have to stomach, have to digest. PTSD means that you’ve developed a medical condition that’s a little bit like epilepsy in which, instead of having a seizure in which you fall down and you get unconscious and you shake, you have a seizure in which you remember what you’d rather not remember.

That’s PTSD, and we’re getting close to seeing it in a brain wave—a very sophisticated analysis of what’s going on in the memory centers of the brain. That’s coming out of research centers in Minnesota, and I’m very taken with this research. I think—I don’t know, but I think—that it’s going to lead to quite a physical understanding of PTSD.

Photo credit: Jon Stephenson

So, if you have PTSD you have a certain kind of a brain injury. It’s not permanent; it gets better by itself. But it’s very, very difficult while you have it, and particularly if you have a severe case.

Severe case means it’s not just severe in that your memory mechanism has been disrupted, and your ability to calm yourself and get back to normal in terms of feeling aroused has been disrupted, and your ability to have a full range of human emotions has been blunted—it’s not just bad for those reasons. It’s bad because of the reality you’ve seen. You’re keeping hell alive, and you’re keeping it alive for the rest of us.

It’s a burden that you carry, and I want to see that burden honored. This is an injury like every other medical injury earned in combat. A medal won’t do a whole lot of good, but I’d feel good to be part of an America that bestows a purple heart for PTSD.